Primary Care Research

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An enhanced pain assessment scale and feedback to hospital nurses can improve pain documentation and analgesic prescribing but not pain reduction

Use of a four-item pain assessment scale along with audit and feedback of patient pain scores to nurses can improve nursing assessment of pain to 85 percent and can significantly improve prescribing of appropriate analgesics. The study involved the staggered implementation of three interventions into two blocks of matched units in one large hospital from April 2002 to February 2003. It is the largest study to date in a U.S. hospital to examine ways to improve the assessment and management of pain among hospitalized patients. The researchers examined the impact of the interventions on pain assessment and severity and analgesic prescribing for 3,946 patients.

Interventions included nurse and physician education given by nurse educators; standardized pain assessment using a one-item or the enhanced four-item pain scale (0 indicated no pain, 1 indicated mild, 2 indicated moderate, and 3 indicated severe); audit and feedback of pain scores to nursing staff; and a computerized decision support system (CDSS). Hospital units using enhanced pain scales had double the pain assessment rates of units using one-item pain scales (64 vs. 32 percent). Audit and feedback of pain results to nurses further increased pain assessment rates compared with units in which audit and feedback was not used (85 vs. 64 percent).

The addition of the CDSS was associated with significant increases in pain assessment only when compared with units without audit and feedback (79 vs. 64 percent). CDSS may not have contributed additional benefits when audit and feedback were used because it did not automatically prompt or require prescribers to use it. The enhanced pain scale was associated with significant increases in prescribed analgesics for patients with moderate or severe pain compared with the one-item scale (83 vs. 66 percent). However, despite the improved prescribing of analgesics, none of the interventions led to reductions in patients' pain. This may have been due to failure to titrate the analgesics to pain relief or patients reporting severe pain may have declined additional analgesia. The study was supported in part by the Agency for Healthcare Research and Quality (HS10539).